A married mother of five sued Anthem, a health insurance company, for its failure to pay for her prosthetic leg. She claims that the company is acting in bad faith in denying her request.
The woman was diagnosed with a cancerous tumor in her left leg when she was 11. Her leg was amputated above the knee, and she was fitted with a prosthesis. She now has five children. In 2016, she was referred to a prosthetist who determined she needed a prosthetic leg with a microprocessor-controlled knee. The prosthetist sought authorization from Anthem for the device.
Anthem denied coverage, stating that the microprocessor-controlled knee prosthesis was not “medically necessary”. The woman appealed the decision. A month later, Anthem denied the request, stating that she did not meet the criteria for a microprocessor device because she did not need to walk more than 400 yards a day at different speeds. She did not need to walk over uneven ground or use stairs outside of her home or workplace, and could not control a complex device. The company found that she did not meet its criteria.
The lawsuit alleges that Anthem’s policy was to deny coverage for microprocessor-controlled knee prostheses as not medically necessary when the requests did not meet all of the company’s erroneous criteria. The lawsuit also alleges that the company failed to assess whether the woman met any valid individual medical criteria for receiving the device.
The lawsuit is seeking to be certified as a class action lawsuit. If you had a request for a prosthetic device denied by Anthem or another insurance company, call me, Conal Doyle, at 310-385-0567. I can help. Call today to learn more or to schedule a free consultation on your case.